PACE Social Worker MSW

The position serves as a primary source to coordinate all transitions of care, mental, and psychosocial care as well as counsels participant on financial and advanced care planning options including advanced directives, DNR, etc. Advocates for participants and ensures participants’ wishes are enacted.  

Duties/Responsibilities: 

• Serves as primary point of contact for all transitions of care. Arranges for beds as needed for appropriate level of care (acute, post-acute, hospice, etc), coordinates all necessary team members including PACE IDT, external care providers, pharmacy, transportation, etc. 

• Finds and obtains access to community resources to support participants and their families. Also organizes caregiver and other appropriate support groups for participants. Identifies resources to meet the psychosocial needs of each participant. 

• Responsible for providing case management services for patients 

• Assists participants and families with DNR, Advanced Directives, etc as needed with an emphasis on ensuring patient’s AD’s are congruent with their disease process. Actively supports participant’s development of end of life plan that is well defined, communicated to family and care team and is in line with participant’s wishes. 

• Performs annual and bi-annual assessments and status change assessments as indicated by Federal and State regulations. 

• Performs routine mental health assessments including depression, anxiety and care giver burnout and makes appropriate referral for mental health services and caregiver support as needed. 

• Provides and recommends participants attendance to appropriate group counseling to support effective mental health hygiene and coping skills for participants.    

• Facilitates care planning meetings, family meetings, and meetings with other care teams such as nursing home, etc. 

• Any and all other duties and responsibilities as assigned.   

#PACE

Required Skills/Abilities:  

• Excellent verbal and written communication skills.  

• Excellent interpersonal and customer service skills. 

• Excellent organizational skills and attention to detail. 

• Exhibits caring attitude toward patients and families  

• Excellent time management skills with a proven ability to meet deadlines. 

• Strong analytical and problem-solving skills. 

• Ability to function well in a fast-paced and agile environment. 

• Proficient with Microsoft Office Suite or related software. 

Education, Licenses, Certifications and Experience: 

• Master’s degree in Social Work (MSW) from an accredited institution is required.  

• At least one (1) year experience working with the frail or elderly population is highly desirable. 

• Current valid Driver’s License and proof of auto liability coverage required. 

• Current LCSW certification preferred.